KDIGOAKI诊疗指南专题知识医学课件

KDIGOAKI诊疗指南专题知识KDIGOAKI诊疗指南专题知识第1页急性肾损伤(AKI)与急性肾衰竭(ARF)国际肾脏病和抢救医学界将ARF改为急性肾损伤（AcuteKidneyInjury,AKI）。AKI覆盖肾损伤WarnockDG.JAmSocNephrol16:3149-3150,BiesenWVetal.CJASN.GFR正常伴肾脏损伤的标志物改变GFR开始下降GFR明显异常KDIGOAKI诊疗指南专题知识第2页AboutAKIguidelineADQI:,RIFLEAKIN:,modifieddefinitionandstagingsystemKDIGO:,FirstclinicalguidelineforAKIWaitingforpublishedinthissummerAKIguidelineforAKI:UKRenalAssociationFinalVersion08.03.11AKIguidline—KDIGOKDIGOClinicalPracticeGuidelineforAcuteKidneyInjuryKDIGOAKI诊疗指南专题知识第3页AKI流行病学现实状况患病率:1%（小区）~7.1%（医院）人群发病率:486~630pmp/yAKI需要RRT发病率:22~203pmp/y医院取得AKI死亡率:10~80%合并多脏器功效衰竭死亡率:>50%需要RRT诊疗者死亡率:高达80%KDIGOAKI诊疗指南专题知识第4页指南推荐强度KDIGOAKI诊疗指南专题知识第5页指南推荐强度KDIGOAKI诊疗指南专题知识第6页Guideline1:AKI定义与分期符合以下情况之一者即可被诊疗为AKI:①

48小时内Scr升高超出26.5μmol/L(0.3

mg/dl);②

Scr

升高超出基线1.5倍—确定或推测7天内发生;③

尿量＜0.5

ml/（kg·h）,且连续6小时以上。单用尿量改变作为判定标按时,需要除外尿路梗阻及其它造成尿量降低原因采取KDIGO推荐定义和分期标准KDIGOAKI诊疗指南专题知识第7页AKI分期标准指南推荐血清肌酐和尿量仍然作为AKI最好标志物(1B)KDIGOAKI诊疗指南专题知识第8页RIFLE分级年急性透析质量倡议组(ADQI)制订了ARFRIFLE分级诊疗标准。BellomoR,etal.CritCare;8:R204-R212KDIGOAKI诊疗指南专题知识第9页ConceptualmodelforAKIKDIGOAKI诊疗指南专题知识第10页Guideline2:临床评定2.1具体病史采集和体格检验有利于AKI病因判定(1A)2.2二十四小时之内进行基础检验,包含尿液分析和泌尿系超声(怀疑有尿路梗阻者)(1A)KDIGOAKI诊疗指南专题知识第11页Chapter2.2:RiskassessmentKDIGOAKI诊疗指南专题知识第12页Chapter2.2:RiskassessmentKDIGOAKI诊疗指南专题知识第13页AKIisdefinedasanyofthefollowing(NotGraded):

·AKIisdefinedasanyofthefollowing(NotGraded):

KIncreaseinSCrbyX0.3mg/dl(X26.5lmol/l)within48hours;

·or

KIncreaseinSCrtoX1.5timesbaseline,whichisknownorpresumedtohaveoccurredwithintheprior7days;

·orKUrinevolumeo0.5ml/kg/hfor6hours.

TestpatientsatincreasedriskforAKIwithmeasurementsofSCrandurineoutputtodetectAKI.(NotGraded)

Individualizefrequencyanddurationofmonitoringbasedonpatientriskandclinicalcourse.(NotGraded)

EvaluatepatientswithAKIpromptlytodeterminethecause,withspecialattentiontoreversiblecauses.(NotGraded)

hecauseofAKIshouldbedeterminedwheneverpossible.(NotGraded)

DefinitionandstagingofAKIKDIGOAKI诊疗指南专题知识第14页OverviewofAKI,CKD,andAKD.OverlappingovalsshowtherelationshipsamongAKI,AKD,andCKD.AKIisasubsetofAKD.BothAKIandAKDwithoutAKIcanbesuperimposeduponCKD.IndividualswithoutAKI,AKD,orCKDhavenoknownkidneydisease(NKD),notshownhere.AKD,acutekidneydiseasesanddisorders;AKI,acutekidneyinjury;CKD,chronickidneydisease.KDIGOAKI诊疗指南专题知识第15页AKD

acutekidneydiseasesanddisorder符合以下任何一项AKI,符合AKI定义3个月内在原来基础上,GFR下降35%或Scr上升50%GFR<60ml/min/1.73m2,<3个月肾损伤<3个月KDIGOAKI诊疗指南专题知识第16页AKI/CKD/AKD肾功能改变肾脏结构改变AKI7天内血肌酐升高50%2天内血肌酐升高0.3mg/dl少尿CKDGFR<60ml/min/1.73m2>3个月>3个月AKDAKI3个月内在原来基础上，GFR下降35%或Scr上升50%GFR<60ml/min/1.73m2,<3个月<3个月NKD无异常KDIGOAKI诊疗指南专题知识第17页Guideline3:PreventionandTreatmentofAKI3.1评定危险原因(1B)年纪>75岁CKD(eGFR<60ml/min/1.73m2心力衰竭动脉粥样硬化性周围血管病变肝脏疾病糖尿病肾毒性药品使用低血容量感染3.2评定容量状态后合适补液(1B)HIGHRISKKDIGOAKI诊疗指南专题知识第18页3.3造影剂肾病3.4继发于横纹肌溶解AKI给予0.9%氯化钠和碳酸氢钠扩容(1B)对具CI-AKI高风险者:提议采取等渗或低渗造影剂提议口服或静脉使用N

-乙酰半胱氨酸（NAC）及等渗晶体预防CI-AKI推荐使用等渗氯化钠或碳酸氢钠静脉扩容以预防CI-AKIKDIGOAKI诊疗指南专题知识第19页Guideline4:AKI诊疗通常诊疗(1A)KDIGOAKI诊疗指南专题知识第20页Stage-basedmanagementofAKIChapter2.3:EvaluationandgeneralmanagementofpatientswithandatriskforAKIKDIGOAKI诊疗指南专题知识第21页补液诊疗Intheabsenceofhemorrhagicshock,wesuggestusingisotoniccrystalloidsratherthancolloids(albuminorstarches)asinitialmanagementforexpansionofintravascularvolumeinpatientsatriskforAKIorwithAKI.(2B)Werecommendtheuseofvasopressorsinconjunctionwithfluidsinpatientswithvasomotorshockwith,oratriskforAKI.(1C)Wesuggestusingprotocol-basedmanagementofhemodynamicandoxygenationparameterstopreventdevelopmentorworseningofAKIinhigh-riskpatientsintheperioperativesetting(2C)orinpatientswithsepticshock(2C)KDIGOAKI诊疗指南专题知识第22页补液诊疗:低血容量者:反复小剂量补液(250ml晶体液/胶体液）亲密监测CVP和尿量监测乳酸和碱剩下水平严重脓毒血症者:慎用高分子量羟乙基淀粉KDIGOAKI诊疗指南专题知识第23页药品诊疗(1B)多脏器功效衰竭药代动力学改变（分布容积、清除、与蛋白结合）需要调整药品剂量KDIGOAKI诊疗指南专题知识第24页现在无特殊药品用于诊疗继发于低灌注损伤/脓毒血症AKI(1B)袢利尿剂againstMehtaRL,PascualMT,SorokoSetal.Diuretics,mortality,andnonrecoveryofrenalfunctioninacuterenalfailure.JAMA;288:2547-2553HoKM,SheridanDJ.Meta-analysisoffrusemidetopreventortreatacuterenalfailure.BMJ;333(7565):420-425KDIGOAKI诊疗指南专题知识第25页Chapter3.4:TheuseofdiureticsinAKIWerecommendnotusingdiureticstopreventAKI.(1B)WesuggestnotusingdiureticstotreatAKI,exceptinthemanagementofvolumeoverload.(2C)KDIGOAKI诊疗指南专题知识第26页Effectoffurosemidevs.controlonall-causemortality.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia;65:283–293withpermissionfromJohnWileyandSons193;KDIGOAKI诊疗指南专题知识第27页Effectoffurosemidevs.controlonneedforRRT.ReprintedfromHoKM,PowerBM.Benefitsandrisksoffurosemideinacutekidneyinjury.Anaesthesia;65:283–293withpermissionfromJohnWileyandSons193;KDIGOAKI诊疗指南专题知识第28页TheuseofdiureticsinAKIAtpresent,thecurrentevidencedoesnotsuggestthatfurosemidecanreducemortalityinpatientswithAKI.abeneficialroleforloopdiureticsinfacilitatingdiscontinuationofRRTinAKIisnotevident.KDIGOAKI诊疗指南专题知识第29页甘露醇mannitolisnotscientificallyjustifiedinthepreventionofAKI.KDIGOAKI诊疗指南专题知识第30页Vasodilatortherapy:dopamine,

fenoldopam,andnatriureticpeptidesWerecommendnotusinglow-dosedopaminetopreventortreatAKI.（1A）Wesuggestnotusingfenoldopam（非诺多巴）topreventortreatAKI.(2C)Wesuggestnotusingatrialnatriureticpeptide(ANP)toprevent(2C)ortreat(2B)AKIKDIGOAKI诊疗指南专题知识第31页Effectoflow-dosedopamineonmortality.ReprintedfromFriedrichJO,AdhikariN,HerridgeMSetal.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.AnnInternMed;142:510–524withpermissionfromAmericanCollegeofPhysicians212;KDIGOAKI诊疗指南专题知识第32页多巴胺---不提议FriedrichJO,AdhikariN,HerridgeMS.Meta-analysis:low-dosedopamineincreasesurineoutputbutdoesnotpreventrenaldysfunctionordeath.AnnInternMed;142:510-524降低肾灌注(Lauschke,KidneyInt)造成心律失常(Schenarts,CurrentSurgery)加重心肌、肠道缺血缺氧(Schenarts,CurrentSurgery)非诺多巴---不提议选择性多巴胺A1受体激动剂,在降低全身血管阻力同时增加肾血流量RESEARCHRECOMMENDATION:WerecommendfurthertrialsofANPatdosesbelow0.1mg/kg/min,forthepreventionortreatmentofAKI.ThereisapossibilitythatANPmightbeeffectiveifitisgivenatalowerdose(0.01–0.05mg/kg/min)inpatientsprophylacticallyorwithearlyAKI,andduringalongerperiodthaninpreviouslargestudie;KDIGOAKI诊疗指南专题知识第33页GlycemiccontrolandnutritionalsupportIncriticallyillpatients,wesuggestinsulintherapytargetingplasmaglucose110–149mg/dl(6.1–8.3mmol/l).(2C)Wesuggestachievingatotalenergyintakeof20–30kcal/kg/dinpatientswithanystageofAKI.(2C)WesuggesttoavoidrestrictionofproteinintakewiththeaimofpreventingordelayinginitiationofRRT.(2D)Wesuggestadministering0.8–1.0g/kg/dofproteininnoncatabolicAKIpatientswithoutneedfordialysis(2D),1.0–1.5g/kg/dinpatientswithAKIonRRT(2D),anduptoamaximumof1.7g/kg/dinpatientsoncontinuousrenalreplacementtherapy(CRRT)andinhypercatabolicpatients.(2D)WesuggestprovidingnutritionpreferentiallyviatheenteralrouteinpatientswithAKI.(2C）KDIGOAKI诊疗指南专题知识第34页GrowthfactorinterventionWerecommendnotusingrecombinanthuman(rh)IGF-1topreventortreatAKI.（1B）humanIGF-1:重组人胰岛素样生长因子1KDIGOAKI诊疗指南专题知识第35页Preventionofaminoglycoside-and

amphotericin-relatedAKIWesuggestnotusingaminoglycosidesforthetreat-mentofinfectionsunlessnosuitable,lessnephro-toxic,therapeuticalternativesareavailable.(2A)Wesuggestthat,inpatientswithnormalkidneyfunctioninsteadystate,aminoglycosidesareadministeredasasingledosedailyratherthanmultiple-dosedailytreatmentregimens.(2B)Werecommendmonitoringaminoglycosidedruglevelswhentreatmentwithmultipledailydosingisusedformorethan24hours.(1A)Wesuggestmonitoringaminoglycosidedruglevelswhentreatmentwithsingle-dailydosingisusedformorethan48hours.(2C)Wesuggestusingtopicalorlocalapplicationsofaminoglycosides(e.g.,respiratoryaerosols,instilledantibioticbeads),ratherthani.v.application,whenfeasibleandsuitable.(2B)KDIGOAKI诊疗指南专题知识第36页Preventionofaminoglycoside-and

amphotericin-relatedAKIWesuggestusinglipidformulationsofampho-tericinBratherthanconventionalformulationsofamphotericinB.(2A)Inthetreatmentofsystemicmycosesorparasiticinfections,werecommendusingazoleantifungalagentsand/ortheechinocandinsratherthanconventionalamphotericinB,ifequaltherapeuticefficacycanbeassumed.(1A)KDIGOAKI诊疗指南专题知识第37页OthermethodsofpreventionofAKI

inthecriticallyillWesuggestthatoff-pumpcoronaryarterybypassgraftsurgerynotbeselectedsolelyforthepurposeofreducingperioperativeAKIorneedforRRT.(2C)WesuggestnotusingNACtopreventAKIincriticallyillpatientswithhypotension.(2D)Werecommendnotusingoralori.v.NACforpreventionofpostsurgicalAKI.(1A)CI-AKI:预防对比剂急性肾损害KDIGOAKI诊疗指南专题知识第38页Guideline5:医疗资源合理分配多学科参与AKI指南制订肾科医生会诊提供专科意见合理转诊方案亲密监护诊疗肾脏科与ICU医生协作Whentorequestarenalreferral？KDIGOAKI诊疗指南专题知识第39页Guideline6:RRT模式选择提议个体化诊疗!(1B)Kanagasundaram,KDIGOAKI诊疗指南专题知识第40页Guideline7:

透析器和透析液选择透析器:合成膜透析器(1B)改良纤维素膜透析器(1B)透析液:首选碳酸氢钠透析液/置换液(1C)透析液微生物控制KDIGOAKI诊疗指南专题知识第41页Guideline8:血管通路临时建立静脉-静脉通路(1A)选择足够长度透析导管以降低再循环率(1B)置管部位和导管类型需依据患者病情选择(2C)由经验丰富医生负责置管(1A)实时超声导引有利于置管(1D)对有进展至CKD4-5期风险患者,尽可能避免行锁骨下静脉置管,保护患者血管资源(1D)KDIGOAKI诊疗指南专题知识第42页Guideline8:血管通路保护非优势侧上肢血管(2C)定时更换临时导管以降低感染风险(1C)颈内静脉:3周股静脉:1周>3周:提议用皮下隧道导管导管仅限于RRT诊疗时使用(1D)以预防感染KDIGOAKI诊疗指南专题知识第43页Guideline9:体外抗凝依据患者病情和RRT模式制订抗凝诊疗方案(1C)推荐枸橼酸局部抗凝降低出血风险(2C)含有出血风险患者可选择前列环素抗凝,但会引发血流动力学不稳定(2C)含有高出血风险患者可采取无抗凝剂、盐水冲洗方法,但引发超滤量增加,透析效率下降及增加了透析膜破裂风险(2C)KDIGOAKI诊疗指南专题知识第44页Guideline10:RRT处方经过对RRT剂量评定确保透析充足性(1A)每次(IHD）或每日（CRRT)评定透析剂量及充足性(1A)推荐伴有多器官功效衰竭AKI患者行CRRT,后稀释法超滤率>25ml/kg/hr。前稀释法连续性血液滤过对应上调超滤率(1A)伴有多器官功效衰竭AKI患者行间歇性血液透析诊疗诊疗时,必需达成单次透析URR>65%或eKt/V>1.2,或者进行每日透析(1B)KDIGOAKI诊疗指南专题知识第45页CRRT剂量Werecommenddeliveringaneffluentvolumeof20–25ml/kg/hforCRRTinAKI(1A).Thiswillusuallyrequireahigherprescriptionofeffluentvolume.(NotGraded)KDIGOAKI诊疗指南专题知识第46页KDIGOAKI诊疗指南专题知识第47页顽固性高钾血症>6.5mmol/L血尿素氮>27mmol/L难以纠正的代谢性酸中毒PH<7.15难以纠正的电解质紊乱:低钠血症、高钠血症或高钙血症肿瘤溶解综合症伴有的高尿酸血症和高磷酸盐血症尿素循环障碍和有机酸尿症导致的高氨血症和甲基丙二酸血症尿量<0.3ml/kg/h持续24h或者无尿